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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002902
Report Date: 05/01/2024
Date Signed: 05/01/2024 10:50:22 AM

Document Has Been Signed on 05/01/2024 10:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:UNITY MEMORY HOME CAREFACILITY NUMBER:
345002902
ADMINISTRATOR/
DIRECTOR:		LIU, YINGFACILITY TYPE:
740
ADDRESS:8161 CHIMANGO COURTTELEPHONE:
(916) 301-8792
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 6CENSUS: 5DATE:
05/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Caregiver- Avonett JohnTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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On 05/01/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Case Management Incident visit. LPA met with caregiver, Avonett John, and explained the purpose of the visit. LPA requested for caregiver to notify Administrator, Ruby Liu, of LPA's presence at the facility. Administrator was unable to meet at the facility and gave caregiver permission to assist LPA during today's visit.

The purpose of the visit is to gather additional information regarding an unusual incident/injury report that was sent to Community Care Licensing (CCL) on 04/25/2024. The report indicates that Resident #1 (R1) had a fall sustaining injury which resulted in R1 having surgery.



During today’s visit LPA obtained a copy of R1s file and conducted an interview with administrator via phone call. LPA also interviewed Staff #1 (S1) and Resident #2 (R2) who were present during the time of R1s fall. R1 is currently still out of the facility.

At this time, deficiencies are not being cited.



An exit interview conducted and copy of the report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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